Kaiser covers the sleeve?
So, for those with Kaiser, I found this link stating their criteria for referral:
But I need to know how many years of documentation they need at a particular BMI. For instance, Aetna (my insurer) wants two years of documented proof at your qualifying BMI.
Also, that document is their "referral criteria." Do they have a separate qualifying criteria to meet? Or is this it?
My husband's company has open enrollment at the beginning of the year and we can switch from Aetna to Kaiser but I need to make sure that it would be worth it for me based on my medical history. I know Aetna has approved some VSGs but I think it's still rare that they will. The surgeon today said he has never had Aetna approve a single VSG so far, even when his office did appeals and he did a peer-to-peer with Aetna.
Oh, great, I just noticed this part:
The patient must be under the care of a PMG
physician for an appropriate period of time for the
physician to be familiar with the patient's medical,
social and psychological status prior to referral.
Well, geez, what do they consider an appropriate period of time? Ugh, this is all so discouraging. Mexico is looking better and better.
on 11/14/09 3:57 pm
Yes, Kaiser does cover the sleeve. That was my reason to switch my insurance provider when I had wasted almost two years trying to get qualified with HealthNet, as it seems to be the case with Aetha for you. In the end, they decided I did not have a medical reason for VSG, which I later came to find out was not the truth (asthma).
The process at Kaiser is lengthy, but the staff, in fact the whole team runs like a well tuned machine. They are coordinated, and require you to attend different workshops, and such. In the end, you come out a better informed patient before getting surgery.
I'm three days out, and very happy with the team here in NorCal. They do cover it, but you have to make a case for it, but honestly, in the end, if like me, that's what you feel is the right surgery for you, they will respect your decision instead of pushing you towards bypass (which happened with me and I still got sleeved!).
Here, in Colorado, it took a year from starting the weight loss journey until I got my sleeve. I attended a 7 week "Weight Connections" class.
Then had once a month sessions with the weight loss counselor for about 5 months, then took a 12 week "Surgical Connections" class.
About a month later (after a psych eval), I got my sleeve.
This was in October of '08. Since then I have attended once a month sessions with the weight loss counselor.
I got the sleeve with Kaiser although it wasn't officially offered as an option. All the literature and pre-surgeon appointments I had discussed only band and RNY. It was my surgeon who looked at my medical history (I've had three prior abdominal area surgeries) and suggested doing the sleeve because of scarring interference concerns.
The process, no matter which procedure, takes most about a year in Northern Cal, I hear. (Although if you cram, you might be able to do it in less time.) There was a multi-week info/support class, an orientation, a nutrition class (1/2 day), a lifestyle class (1/2 day), dr's appointment for a referral, obgyn appointment (mandatory for the referral), psych eval appointment ... and then the multiple surgeon appointments as I prepped.
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Hey Laura, I just had my psych eval friday in Fremont. Dr Hahn has already emailed me saying I can get a VSG...So now I wait for a date...
Ok Mandy, here is my experience...Also you can read my profile to see how long, and why its taken 3yrs...
Anyhoo, we switched to Kaiser cause it was the cheapest ins. offered. I asked my PCP for a referral to the Bariactric program, and she referred me that day.
I got an appt. for the orientation meeting Nov or Dec 2008.
I got an appt. for a surgical consult for January 2009. At that appt. I was told to lose 10% (30lbs.) We are required to call in our wt. every month
Since the VSG wasn't offered until very recently, I didn't do the psych eval till yesterday. Now I wait for a date..
I didn't have to attend any "classes" for anything.
I've heard of folks speeding the process along by losing the 10% fast. Especially if "classes" aren't required...
So all in all, Ya, its taken me a year, but remember, the VSG was not an option so I took my time, hoping it would be offered eventually.
Many Kaisers offer the VSG across the country, just depends on the area...
The main thing is to get the referral to the Bariactric program, and YOUR Kaiser will tell you all the requirements...
I have to tell you that we never cared for Kaiser. Bad past experiences. Iam SO impressed with the changes they have made, and really like Kaiser now. They are so darn organized!
Hope this helps!
I believe my mom has Kaiser now, or had it until she recently retired, and she loved it. I am glad to hear they have changed.
Truthfully, I'm not a fan of HMOs in general, but what can ya' do.
Kaiser is a low stress way to go, you don't need to deal with appeals and a lot of requirements, you just need to be patient with their process. Most people lose weight on their own during that year while they are waiting which helps make the surgery safer and the recovery easier.
They do their darndest to inform you and to ease you into the wls lifestyle. I read about folks who had little pre-op prep, and I think, "Wow, the transition to the post-op life must be overwhelming for you." I'd already spent months weaning myself off my great obsession -- bread items. I'd pared down portions, started working with the food scale and the food journal. etc. ... I was one of those folks who had complications -- and even That I was somewhat prepared to deal with because of the Kaiser program. Now that I'm a 'regular' post-op gal, I feel confident moving forward. I hope you have the same (minus the complications) experience!
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on 11/14/09 8:20 pm
The process does take an year with the orientation, lifestyle classes and such. Please do take advantage of these options, looking back now I'm glad they held me accountable for the things I needed to do. I tried to use my gallstones as an excuse to try to expedite my surgery date, but they did not fall for it, and in the end I had to lose the required 10% pre-surgery weight.
If you are able to lose your 10% weight, from your weigh in day, the whole process will take less than a year (at least that is the case here in Northern California). Good luck to you, and again, I agree with other posters that Kaiser's process for VGS is much easier.
Oh also, with Kaiser, can I still go to any Emergency Room? I have bad back problems and gall bladder problems that have sent me to the ER twice in the past 6 months.
I talked to DH about changing insurance to Kaiser. We really really love our pediatrician that we have and I hate to lose her (I drive 45 minutes just to take the kids to her, that's how much I love her!), but he said we can always switch back to Aetna eventually if we want.
Check out my profile for info on WLS for Type 2 Diabetes.
Highest Known Weight: 324 - Weight on Morning of Surgery: 308.5
Lowest Post-op Weight: 180 (currently working on losing baby weight!)
Post-WLS baby Benjamin David born 3/24/2012, 7 pounds 11 ounces, 19 inches!